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Mental health and wellbeing support when you have a heart condition - patient information

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This factsheet contains a list of useful mental health and wellbeing support services and resources for people living with a heart
Url
/Media/UHS-website-2019/Patientinformation/Cardiovascular-and-thoracic/Mental-health-and-wellbeing-support-when-you-have-a-heart-condition-4012-PIL.pdf

Managing pain after surgery

Description
pain management after surgery v2.qxp_Layout 1 09/06/2022 12:21 Page 1 Managing pain after your surgery This leaflet explains what you can do to prepare for going home after surgery and to help your recovery. It describes the medicines used to reduce pain, and how to use them safely while you recover. pain management after surgery v2.qxp_Layout 1 09/06/2022 12:21 Page 2 Why have I been prescribed pain medicines? Some pain after an operation or surgery is normal. The amount of pain will be different for everybody. It’s known as acute pain and it can be lessened with pain medicines. You will usually be offered pain medicines straight after your operation. Your healthcare team will develop a plan that includes pain medicines you may already be taking. These reduce the pain. This makes it easier to cough, move, walk about and become steadily more active. These activities are vital to your recovery. It is normal to feel anxious about moving again after surgery. As you recover and gradually increase your activity level, you may notice that your confidence grows as well. It is important to have a plan to help you get there. Perhaps you might want to try something new or do things in a different way. Pain medicines also make it easier to follow the exercise plan from your physio team, so you recover more quickly. Being active reduces the risk of complications such as chest infection or clots in the legs or lungs. As you feel better, stronger and are more active, you should reduce and then stop your pain medicines. If pain persists, contact your healthcare team. 2 pain management after surgery v2.qxp_Layout 1 09/06/2022 12:21 Page 3 Opioid medicines: the basics Opioid medicines such as morphine are useful to help reduce higher levels of pain experienced after an operation or injuries like a fractured bone. They are usually prescribed when other pain medicines have not reduced the level of pain enough to allow you to comfortably increase what you are able to do e.g. physiotherapy, getting up and moving about. There are different types of opioid pain medicines and they might be used at different times in your recovery or vary depending on other medicines that you are also taking. You may only need opioid medicines for a short time after surgery. Most people stop them after a couple of days. If you need to take them for longer, it is important to reduce and stop them in a planned way. You may be advised to take other pain medicines as you recover. Your healthcare team will advise you on the type of opioid medicine to use. They can guide you to use pain medicines safely to reduce the chance of side effects or other problems. Your healthcare team will also recommend how you can best reduce and stop taking pain medicines as soon as you feel able to. 3 pain management after surgery v2.qxp_Layout 1 09/06/2022 12:21 Page 4 Before your surgery What can I do before my operation to improve my recovery afterwards? Be as active and fit as you can be Being as active and fit as you can be helps recovery to be quicker and the pain will reduce and stop sooner. Sometimes staying active can be tricky if you have pain or problems with joints or other areas of the body. So ask for advice about how to increase your body and heart fitness. Regular gentle walking several times a day, water-based exercise and exercises done in your chair can all help build fitness. Pace these activities so as not to cause pain or symptom flare ups. Steady and gentle approaches everyday are the most helpful. Eat healthily Healthy eating helps wounds to heal. So explore ways to eat more healthy foods, like fruit and vegetables. Losing extra weight helps reduce many complications, like wound infections. Even small weight loss helps better healing. 4 pain management after surgery v2.qxp_Layout 1 09/06/2022 12:21 Page 5 Reduce or stop smoking and vaping This helps lessen the risk of a chest infection, clots in the legs and lungs and other health issues that make your recovery tougher and longer. Reduce or stop alcohol This can help the body recover faster after your operation. Use enjoyable distraction and relaxation • Bring enjoyable and easy-to-read books into hospital • Listen to music or podcasts you enjoy • If you find relaxation or mindfulness techniques helpful, use them through the day, and at night if sleep is difficult • Audio versions of books, relaxation and mindfulness recordings are worth bringing into hospital too What if I’m already taking opioids? If you are already taking opioids, please talk to your healthcare team. Depending on timing of your surgery, you may benefit from reducing your opioids beforehand in a safe manner. This may help with recovery after surgery, particularly in terms of your pain management, wound healing or reducing the risks of infections in body areas like the skin, chest or mouth. 5 pain management after surgery v2.qxp_Layout 1 09/06/2022 12:21 Page 6 How medicines reduce pain Paracetamol is thought to relieve pain by blocking chemical messengers in the brain and spinal cord. Non-steroidal anti-inflammatory drugs (also known as NSAIDs) such as Ibuprofen block the production of certain body chemicals that cause inflammation and pain. Opioids (for example codeine, tramadol and morphine) provide pain relief by acting on areas in the spinal cord and brain to block the transmission of pain signals. Opioids are considered to be some of the strongest pain medicines. You should reduce and then stop taking opioids as soon as you can, or by the date on your pain management plan. This is because of the risk of becoming dependent or addicted to them. If you find it difficult to stop taking opioids by the time agreed in the plan, talk to your healthcare team to find other ways of stopping opioids and lessening your pain. For further information on all pain medicines, read the patient information leaflet provided with the medicine. 6 pain management after surgery v2.qxp_Layout 1 09/06/2022 12:21 Page 7 Using a pain management plan One thing you can do to help your recovery after surgery is to use a pain management plan. There’s a plan printed on the following pages for you to use. A member of your healthcare team will work with you on your plan to fill it in. This will then become your personal Pain Management Plan. It will show you which medicines to take, when to take them and when to reduce and stop them safely. Take the plan home with you and use it to remind you how to use your medicines safely and when you should be reducing and stopping them. 7 pain management after surgery v2.qxp_Layout 1 09/06/2022 12:21 Page 8 My Pain Management Plan My name Filled in by (healthcare team member) Date filled in 1. The pain medicines I have been given Opioids Tick the ones prescribed Tramadol Morphine Oxycodone Tapentadol Other? Codeine Dihydrocodeine Other? NSAIDs Ibuprofen Naproxen Diclofenac Other? Paracetamol Paracetamol The dose How often I should take them 8 pain management after surgery v2.qxp_Layout 1 09/06/2022 12:21 Page 9 NOTE: Paracetamol (shown below in green), the NSAIDs (shown in yellow) and the opioids shown in orange should be taken at regular times during the day. The opioids shown in red should only be taken when you need them. 2. When I should be reducing and stopping them The date I started Day 1 The date I should reduce and stop taking them 9 pain management after surgery v2.qxp_Layout 1 09/06/2022 12:21 Page 10 After your surgery Going for gentle, regular walks is a great way of staying active When you leave hospital, you will receive a pain management plan and a prescription for pain medicines. The pain medicines will help manage your pain levels so you can be as active and independent as possible. The pain levels will lessen as your body heals and you steadily increase your daily physical activities in your home and outside. If you are still struggling with high levels of pain even with pain medicines, you should ask for a review with your healthcare team. 10 pain management after surgery v2.qxp_Layout 1 09/06/2022 12:21 Page 11 What can I do after my operation to reduce pain and recover well? Manage your medicines safely Follow the advice on the best way to use your pain medicines so you make a good recovery. Remember to take pain medicines (such as paracetamol and ibuprofen) regularly, as written in your pain managment plan on page 8. Learn to pace your activity Try not to overdo things just because you’re having a ‘good day.’ This is sometimes called a “boom or bust cycle” and is unhelpful for a steady recovery. It can make you overtired so that you can’t do anything the next day. Steady pacing of activities is better. Choose activities that help build fitness and do them at regular intervals through the day. You’ll be more likely to keep it up if you choose activities that you find are fun or rewarding. Always stop before you get overtired and remember to build in rest breaks. Stay active Build up your physical activity and do enjoyable daily activities. Activity will help you distract yourself from the pain. For example you can: • go for gentle, regular walks • do enjoyable hobbies or crafts, indoor or garden activities (remember to do these within your recovery limits) Distraction and other techniques • use techniques such as watching fun or gripping films or TV programmes • practise mindfulness, use crosswords and mindfulness colouring books, and try relaxation and breathing techniques 11 pain management after surgery v2.qxp_Layout 1 09/06/2022 12:21 Page 12 More about opioids... Using opioid pain medicines to prevent pain levels increasing Using opioid pain medicines only when you need them will help you recover better. You’ll be able do more daily activities and keep to the exercise plan from your physio team. Think about which activities are likely to increase your pain levels (for example, a longer walk or an outing with friends). You can then plan for these expected increases in pain by taking your strong opioid pain medicines before the activity. This helps keep pain levels controlled. It is the most helpful way to take strong opioids. As your pain lessens, you can reduce pain medicines. Remember: you should aim to stop taking opioids sooner than other pain medicines like paracetamol. 12 pain management after surgery v2.qxp_Layout 1 09/06/2022 12:21 Page 13 Constipation: a common side effect of opioids Constipation is the most common side-effect of opioids and can really upset bowel movements. The most helpful way to reduce constipation is to take action before you are severely constipated. Three useful things to manage constipation well: 1. Drinking fluid helps. You should aim to drink plenty of fluids. 2. Eat foods that you know reduce constipation in you. For some people it can be figs, prunes, breakfast cereals, oranges, beans or pulses. Everyone is different. 3. Take a laxative medicine every day, to soften your ‘poo’ or stools and keep your bowels moving most days of the week. Get advice from a pharmacist or GP on the most useful type of laxatives. There are two types of laxatives: those that soften the stool and those that help move it through and out of the bowel. You might need to take both. Nearly everyone should take laxatives until they stop their opioids. 13 pain management after surgery v2.qxp_Layout 1 09/06/2022 12:21 Page 14 Stay safe while taking opioids after your surgery You should not drive if your ability to do so is impaired. Always lock opioids safely away. Keep them away from children at all times. Start reducing opioids as your pain level improves and interferes less with the things you are trying to do. Never keep leftover opioids at home. Do not throw them in the bin. Always take unused opioids to your local pharmacy for disposal. Tell your carers to call 999 if they can’t wake you up or if your breathing is very slow. Tell them to tell doctors or paramedics you take opioids for pain. 14 pain management after surgery v2.qxp_Layout 1 09/06/2022 12:21 Page 15 For further information: painconcern.org.uk my.livewellwithpain.co.uk flippinpain.co.uk versusarthritis.org My questions If you have any questions about your pain management plan or recovering from your surgery please make a note of them here, to help you remember to ask a member of your healthcare team. 15 pain management after surgery v2.qxp_Layout 1 09/06/2022 12:21 Page 16 Faculty of Pain Medicine College of Anaesthesiologists of Ireland Thanks to Louise Trewern of the British Pain Society’s Patient Voice Committee, for her valuable input to the development of this booklet. Booklet design: Andrassy Media. Version 1, June 2022
Url
/Media/UHS-website-2019/Docs/Services/Pain/Managing-pain-after-surgery.pdf

Welcome to the TAVI clinic - patient information

Description
Information about transcatheter aortic valve implantation (TAVI) - a procedure to replace a faulty aortic (heart) valve via a thin plastic tube.
Url
/Media/UHS-website-2019/Patientinformation/Cardiovascular-and-thoracic/Welcome-to-the-TAVI-clinic-3352-PIL.pdf

Going home after your stay at the major trauma centre - patient information

Description
This factsheet gives you useful information about returning home after your stay at the trauma centre.
Url
/Media/UHS-website-2019/Patientinformation/Major-Trauma-Centre/Going-home-after-your-stay-at-the-major-trauma-centre-3124-PIL.pdf

Papers CoG 29.04.2025 v2

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Date Time Location Chair Agenda Council of Governors 29/04/2025 14:00 - 15:45 Conference Room, Heartbeat/Microsoft Teams Jenni Douglas-Todd 1 Chair’s Welcome and Opening Comments 14:00 2 Declarations of Interest 14:04 3 Minutes of Previous Meeting 14:05 Approve the minutes of the previous meeting held on 29 January 2025 4 Matters Arising/Summary of Agreed Actions 14:06 5 Strategy, Quality and Performance 5.1 Chief Executive Officer's Performance Report 14:07 Receive and note the report Sponsor: David French, Chief Executive Officer Attendee: Gail Byrne, Chief Nursing Officer 5.2 Annual Report and Quality Accounts Timetable 2024/25 14:27 Note the timetable Sponsor: David French, Chief Executive Officer Attendee: Karen Russell, Council of Governors Business Manager 5.3 Draft Quality Accounts 2024/25 14:32 Review and feedback Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Helena Blake, Head of Clinical Quality Assurance 5.4 Corporate Objectives 14:42 Review and feedback Sponsor: David French, Chief Executive Officer Attendee: Kelly Kent, Head of Strategy and Partnerships 5.5 Non-NHS Activity 14:52 Receive and note the update Sponsor: Ian Howard, Chief Financial Officer Attendee: Pete Baker, Commercial and Enterprise Director 5.6 Break 15:02 6 Governance 6.1 Governor Attendance at Council of Governors' Meetings 15:12 Review governor attendance at Council of Governors' meetings Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Karen Russell, Council of Governors' Business Manager 6.2 Council of Governors' Elections 2025 15:17 Note the timetable Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Karen Russell, Council of Governors' Business Manager 6.3 Appointment to the GNC 15:19 Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Karen Russell, Council of Governors' Business Manager 7 Membership Engagement and Governor Activity 7.1 Membership Engagement 15:21 Receive the report Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Sam Dolton, Events and Membership Officer 7.2 Governors' Nomination Committee Feedback 15:31 Chair: Jenni Douglas-Todd, Trust Chair 8 Review of Meeting 15:36 Review and feedback on the content of this meeting Sponsor: Jenni Douglas-Todd, Trust Chair 9 Any Other Business 15:41 Raise any relevant or urgent matters that are not on the agenda 10 Date of Next Meeting: 16 July 2025 15:44 Note the date of the next meeting Page 2 Minutes - Council of Governors (CoG) Open Session Date Time Location Chair Present 29 January 2025 14.00-15.30 Conference Room, Heartbeat Education Centre and Microsoft Teams Jenni Douglas-Todd, Trust Chair Jenni Douglas-Todd, Trust Chair Shirley Anderson, Elected, New Forest, Eastleigh and Test Valley Theresa Airiemiokhale, Elected, Southampton City Katherine Barbour, Elected, Southampton City Patricia Crates, Elected, New Forest, Eastleigh and Test Valley Sandra Gidley, Elected, New Forest, Eastleigh and Test Valley Lesley Gilder, Elected, Southampton City Ben Grassby, Elected, Rest of England and Wales Linda Hebdige, Elected, Southampton City Councillor Pam Kenny, Appointed, Southampton City Council Professor Sue Latter, Appointed, University of Southampton Jenny Lawrie, Elected, Southampton City Brian Lovell, Elected, Rest of England and Wales Councillor Louise Parker-Jones, Appointed, Hampshire County Council Cat Rushworth, Elected, Isle of Wight Karen Smith-Baker, Elected, Health Professional and Health Scientist Staff Jake Smokcum, Elected, Nursing and Midwifery Staff Mike Williams, Elected, New Forest, Eastleigh and Test Valley JDT SA TA KB PC SG LG BG LH PK SL JL BL LPJ CR KSB JS MW In attendance Tracey Burt, Minutes TB Sam Dolton, Events and Membership Officer SD David French, Chief Executive Officer (for item 5.1) DF Steve Harris, Chief People Officer (for item 6.1) SHa Craig Machell, Associate Director of Corporate Affairs and CM Company Secretary Karen Russell, Council of Governors’ Business Manager KR Apologies Professor Cathy Barnes, Appointed, Solent University CB Sathish Harinarayanan, Elected, Medical Practitioners and Dental SH Staff Esther O’Sullivan, Elected, New Forest, Eastleigh and Test Valley EO Liz Taylor, Elected, Non-Clinical and Support Staff LT 1 Chair’s Welcome and Opening Comments The Chair welcomed everyone to the meeting and in particular, BG and SL, who were attending their first CoG, although they had attended the strategy day at the end of last year. 1 2 Declarations of Interest There were no new declarations of interest relating to matters on the agenda. 3 Minutes of Previous Meeting The minutes of the meeting held on 23 October 2024 were approved as an accurate record of the meeting. 4 Matters Arising/Summary of Agreed Actions All actions had been completed. 5 Strategy, Quality and Performance 5.1 Chief Executive Officer’s Performance Report The Chair welcomed DAF who joined the meeting to present the performance report. He highlighted the following from the report and commented on various national issues:- • the Trust had been under significant pressure related to urgent and emergency care. Whilst this was also a national problem, attendances at the UHS Emergency Department had been higher than last year, averaging 448 patients a day. During the Christmas period, attendances and admissions had been exacerbated by Covid-19 and flu. Various Trusts had declared critical incidents but UHS had not, although it had been close to doing so. • pressure on the Emergency Department had eased slightly in January but during the last week it had increased again. At midnight on 27 January 2025 there had been 150 patients in the department, which was double the normal capacity. • infection prevention was a greater challenge when the hospital was under intense pressure but the Trust was focussed on it. • the Trust had seen an increase in Never Events. A theme related to invasive procedures and missed opportunities to stop, before procedures had started, had been identified. A plan to mitigate such events had been put in place and the Trust would implement the National Safety Standards for Invasive Procedures (NatSSIPs). • the Trust’s referral to treatment (RTT) waiting list had remained above 60,000 in quarter three. 62% of patients on the waiting list had been waiting less than 18 weeks, which meant that UHS was in the top quartile when compared to peer teaching hospitals. • UHS had delivered elective recovery fund activity (ERF) at 128% of 2019/20 levels, which was 15% above the Trust’s target. • the physical capacity of the UHS estate continued to be a challenge. • the funding mechanism related to how ERF money was paid, continued to be a challenge for the Trust. It was hoped that national planning guidance, due out on 30 January 2025, would provide clarity. • the annual staff survey had now closed and the Trust was beginning to receive initial results. These would be shared in due course. • there had been a slight increase in staff sickness absence, largely due to Covid-19 and flu. • the Trust had a significant financial deficit and needed to get back to breakeven. 2025/26 was likely to be another difficult year and it was known that three national priorities would be safe emergency care, reductions in the elective waiting list and the need for Trusts to live within their means. BL queried whether the Trust had done everything it could, in terms of its financial situation. DAF advised that UHS had recently received productivity benchmarking data, which showed that it was fourth in the country, when compared to others, so the Trust was struggling to see what it could do better. 2 SG queried whether all activity for 2025/26 had been capped. DAF advised that new operations and elective outpatient procedures were presently paid for on a price per unit basis, whilst almost everything else was on a block contract. UHS was generally doing more activity than the block assumed and it was likely that elective activity would also be capped next year. The Trust may, therefore, need to consider pulling back on the things that added the least value. CR noted that people were generally living longer and asked whether that was being considered, from a financial perspective. DAF advised that UHS would always support clinical decisions, regardless of a patient’s age. The Chair thanked DAF for attending CoG. 6 Governance 6.1 Chair and Non-Executive Director Appraisal Process The Chair welcomed SHa to the meeting and noted that as a Foundation Trust, UHS was required to conduct a robust appraisal process. The process started in January and would conclude in April. The governors had a vital role in providing feedback on the work of the Non-Executive Directors (NEDs) and system partners would also be asked to provide feedback on the Chair. The Chair would conduct the NEDs appraisals and Jane Harwood, Senior Independent Director (SID) would undertake the Chair’s appraisal. SHa advised that NHS England was due to launch a new appraisal process, nationally, for NEDs but it was still outstanding. However, a refreshed appraisal process for Chairs had been released in 2024. SA noted that governors often found it difficult to provide feedback on the NEDs and advised that she had some helpful tips to share with them, at the end of the CoG meeting. Decision: The CoG approved the Chair and NED appraisal process for 2024/25. 6.2 Audit and Risk Committee Terms of Reference CM advised that the Audit and Risk Committee had carried out the annual review of its Terms of Reference and two minor amendments had been proposed: • to amend 10.2 to Code of Governance for NHS Provider Trusts. • to remove Charitable Funds Committee from Appendix A. Decision: the CoG supported the proposed changes to the Audit and Risk Committee Terms of Reference. 6.3 Governors’ Nomination Committee Terms of Reference CM advised that the Governors’ Nomination Committee had reviewed its Terms of Reference on the 15 January 2025 and the CoG was asked to approve the removal of the words “deputy chair” from paragraph 3.2. Decision: the CoG approved the proposed, minor change, to paragraph 3.2. 6.4 Council of Governors’ Annual Business Plan 2025/26 KR advised that each year the CoG was required to review its Annual Business Plan for the coming financial year. Decision: the CoG approved its Annual Business Plan for 2025/26. 3 6.5 Non-Executive Director Appointment The Chair reminded the CoG that at its meeting on 15 April 2024 it had approved the appointment of David Liverseidge as a NED, for a three-year term. However, due to his position at Ramsay Health Care UK and the potential conflict of interest, it had been agreed to delay his appointment until his retirement at the end of 2024. The CoG was therefore asked to note that following completion of the Fit and Proper Persons checks and declaration processes, his appointment as a NED had commenced on 1 January 2025. 6.6 Governor Attendance at Council of Governors’ Meetings KR introduced the report and advised that if a governor failed to attend two successive meetings of the CoG, their appointment would be terminated unless the absences were due to reasonable cause. The Chair, CM or KR would contact the governor, to understand the reasons and would then provide confirmation to the CoG that the causes were reasonable. BL said that he would find it difficult to approve the continued tenure of a governor, if he did not know the reasons for their absence. The Chair clarified that the CoG would be asked to confirm that it was satisfied the Chair or Company Secretary had followed the process, rather than be asked to approve the reasons for any absence. SG queried what was meant by a “reasonable period” and the Chair advised that it would depend on the circumstances, which would be discussed with the individual governor. Action: It was agreed that CM and KR would review the constitution to check whether any amendments to the wording were needed. 7 Membership Engagement and Governor Activity 7.1 Membership Engagement SD introduced the Membership Engagement report and highlighted the following:- • the monthly newsletters continued to keep members updated. • the quarterly Connect digital magazines had been sent out in November 2024 and January 2025. There had been an emphasis on health inequalities in the community, in the latter edition. • the open evening and annual members’ meeting had been held, in person, at UHS in November 2024. It had not been as well attended as he would have hoped (it had snowed that day) and going forward, ways to maximise attendance would be considered. However, there had been positive feedback from those who had attended. • during December 2024 a virtual event, focused on healthy ageing, had been held. He encouraged governors to register for the forthcoming virtual event on cancer research. • due to the extreme pressures on the hospital, the team had actively used social media channels to remind people of the alternatives available, rather than attending the emergency department. • the opening of Woodland Ward, special care baby unit at the Princess Anne Hospital, had featured in the quarterly update. • the continued production of the monthly updates and the Spring edition of the Connect quarterly digital magazine were priorities for the team. 4 • attendance at external events (e.g. the Mela Festival) and opportunities to collaborate with other teams, were being planned and governors were encouraged to offer their support. Governors made the following comments:• it was helpful to have an engaging activity available at external events, as these helped to draw people in. • whether it would be appropriate to attend the Southampton marathon, which attracted a large number of people. SD advised that the team had attended in the past but had not found it the ideal event to have conversations with people. He would, however, contact the hospital charity, to see whether there was information that could be handed out. • SL suggested that she and SD discuss ways to recruit students as members. The Chair thanked SD for his informative report. 7.2 Governors’ Nomination Committee Feedback The Chair advised that the Governors’ Nomination Committee had met on the 15 January. It had undertaken the annual review of its Terms of Reference and had looked at the appraisal process for the Chair and NEDs. It had also noted the commencement of David Liverseidge as a NED. 8 Review of Meeting The governors said that they had found the meeting very informative, with the right level of information provided. 9 Any Other Business The following were mentioned by governors:- • the increased aggression towards staff was noted and the Chair advised that greater detail would be available once the annual staff survey results were available. • KB advised that she had visited Heartbeat House (on the edge of the UHS site) where friends and relatives of patients undergoing cardiac surgery could stay. A coffee morning was held every Tuesday morning in Heartbeat House and KB encouraged governors to attend, as it provided a good opportunity to meet members of the public. She also raised awareness of the Heart & Stroll event being held on 29 June 2025 to raise funds towards the renovation of the Heart Failure Unit at UHS. • CM advised that due to changes in the Hampshire and Isle of Wight Integrated Care Board (ICB) and a possible conflict of interest, the ICB did not intend to replace Helen Eggleton, who had previously represented them as a governor on the CoG. It was therefore proposed to reduce the number of governors to 21, which would require the constitution to be amended. The CoG expressed its disappointment at the ICB’s decision and the Chair agreed to discuss the decision, when she next met with the Chair of the ICB. • the Chair advised that with effect from 11th March, all UHS Trust Board meetings would be held in person. A hybrid option would, however, still be available for the CoG meetings. • the Chair asked governors to ensure that they advised KR of any board committees they wished to attend, at least a week in advance. This would enable KR to liaise with the committee Chair, to ensure that it was appropriate for a governor to attend. 10 Date of Next Meeting The next meeting of the CoG would be held on 29 April 2025. 5 List of action items Agenda item Assigned to Deadline Status Council of Governors 29/01/2025 6.6 Governor Attendance at Council of Governors’ Meetings 1199 Governor Attendance at Council of Governors’ Meetings . Machell, Craig Russell, Karen 29/04/2025 Completed Explanation action item Under the Trust’s constitution if a governor failed to attend two successive meetings of the council of governors, his or her tenure of office is to be immediately terminated by the CoG unless the CoG is satisfied that the absences were due to reasonable cause; and he/she will be able to attend meetings of the CoG within such a period as the CoG considers reasonable. The CoG was happy to confirm it was satisfied that the correct process had been carried out but could not comment on the reasons for absence or their ability to attend future meetings within a reasonable period of time, as these had been a confidential part of the discussion with the governor. CM and KR agreed to look at the Trust's constitution to establish if an amendment was required to the wording regarding this. Explanation Russell, Karen The wording in the constitution relating to this issue requires amendment and this will be carried out when the Trust's constitution is reviewed during 2025/26. In the meantime, the wording in future papers relating to governor attendance at CoG meetings will be adjusted accordingly. Item 5.1 Report to the Council of Governors - 29 April 2025 Title: Chief Executive Officer’s Performance Report Sponsor: David French, Chief Executive Officer Author: Sam Dale, Associate Director of Data and Analytics Purpose (type an ‘x’ in the appropriate box(es)) (Re)Assurance Approval Ratification Information x Strategic Theme (type an ‘x’ in the appropriate box(es)) Outstanding patient Pioneering research World class people outcomes, safety and innovation and experience Integrated networks and collaboration Foundations for the future x x x Executive Summary: Information about Trust performance supports the Council of Governors in their role. This report is intended to inform the Council of Governors about aspects of the Trust’s performance. Contents: The Chief Executive Officer’s Performance Report is attached. Risk(s): N/A Equality Impact Consideration: N/A UHS Council of Governors April 2025 Chief Executive’s Performance Report 1. Purpose and Context The purpose of this report is to summarise the Trust’s performance against a range of key indicators. Where available, this report covers data from the period January to March 2025, noting that some performance data is reported further in arrears and therefore unavailable. As the organisation transitions to the national 25/26 NHS priorities, notable features of 24/25 quarter four include: • The financial position of the organisation remains extremely challenging as the trust prioritises the national request to live within its means despite restrictions on funding for emergency activity and elective growth. • Despite the economic challenges, the organisation continues to benchmark well for productivity measures including theatre utilisation and length of stay whilst recognising there remains an opportunity to go further. • The waiting list continued to grow in quarter four, however the trust has maintained performance on 18 week targets and reduced the volume of patients waiting over 65 weeks to a small cohort of services. • The organisation has maintained robust performance on cancer and diagnostic waiting times and anticipates that the validated year end position will place the organisation in the top quartile compared to peer organisations. • The volume of patients with no criteria to reside remains above 200 per day which continues to place a barrier on our bed availability. • The trust ranking for recommendation as a place to work has improved four places placing UHS at 18th out of 122 trusts. 2. Safety Infection Control Clostridium Difficile infection MRSA Bacterium infection Target 78.0% January 2025 39 35 74 70 40 24 33 7 0 January 2025 63.9% February 2025 44 12 56 46 33 19 27 5 0 February 2025 57.4% March 2025 54 25 79 59 43 25 36 2 0 March 2025 60.1% Performance against the emergency access target continues to be challenging with attendances growing by 3.2% compared to the previous financial year. In March 2025, 60.1% of patients spent less than four hours in the department which places the trust in the third quartile when compared to peer teaching hospitals. There is significant focus on improving this, with the plan based on two areas; improving decision making speed within the Emergency Department and improving timely flow from the department when patients need admission. The former is looking at consistency of practice, speciality in-reach into the department, and ensuring rotas reflect known peaks in attendance. The latter is looking at enhanced access, and increased pathways, to same day emergency care, flow and discharge throughout the hospital and embedding internal professional standards. Referral to Treatment (RTT) Target January 2025 % incomplete pathways within 18 weeks in month Total patients on a waiting list => 92% 62.0% 60,910 February 2025 61.5% 61,333 March 2025 62.5% 61,686 Whilst the trust continues to deliver more elective activity year on year, the RTT (referral to treatment) waiting list has continued to climb in each month of quarter four peaking at 61,686 at the end of the financial year. Despite this the organisation has maintained performance of 62% for the percentage of patients on the waiting list who are below 18 weeks. The trust ensures the appropriate prioritisation of our longest waiting patients with those of more urgent clinical need. The hospital reported just one patient waiting over 78 weeks in March 2025 due to the continued national delays for corneal tissue release. There were 21 patients waiting over 65 weeks - whilst some were also corneal transplant patients, others were services impacted by the prioritisation of urgent cancer patients or services managing unexpected emergency demand. Page 3 of 5 The trust is now transitioning focus to new 25/26 national waiting list targets. The organisation is committed to maintaining the strong improvements seen in 24/25 for theatre utilisation, length of stay reduction and optimisation of outpatient clinics. Alongside this, the organisation is closely reviewing referral trends and opportunities to manage them through increased advice and guidance. Cancer Target Faster Diagnosis - within 28 days 31 Day target - decision to treat to first definitive treatment 62 day target - urgent referral to first definitive treatment > =77% => 96% => 70% December 2024 83.6% 94.9% 82.2% January 2025 80.6% 95.1% 79.9% February 2025 84.4% 92.8% 72.1% The organisation continues to prioritise cancer patients and their treatments for all tumour sites and cancer types. The trust has maintained its strong performance against the 28 day faster diagnosis standard, consistently hitting the target and benchmarking in the top quartile compared to peer teaching hospitals across the country. Diagnostic capacity and the impact of provider referrals into UHS specialised services impacted our 62 day performance in February but unvalidated data provides assurance that the position has recovered to above 80% in March 2025. 5. Finance The financial environment remains extremely challenging for UHS. One off income received by the ICB and several technical adjustments have however helped reduce the scale of the deficit to £7m at the end of February 2025. This is £3.7m behind the annual plan of £3.3m deficit. The trust is targeting a breakeven position in March 2025 to ensure the deficit doesn’t further deteriorate and HIOW ICS can achieve a breakeven position for the year. The trust’s underlying position, so removing one off income, is significantly more challenging than this with an underlying deficit of c£6.5m per month. The organisation therefore continues to put significant focus on financial recovery with the aim of ensuring the organisation ‘lives within its means’ and makes progress towards the delivery of a breakeven run rate. The deficit drivers remain similar to those previously reported, focusing on three key areas: 1. Urgent and Emergency activity is in excess of block funding levels by c£2m per month. This has meant surge capacity has been required across all months of the financial year with peak usage in winter months. Demand management schemes are under development with HIOW ICS partners as part of agreeing plans for 2025/26 as is an increased funding envelope. 2. Non-criteria to reside numbers have increased to peaks of 250 from an average of 220. This is c20% of the trusts bed base and has a significant cost in addition to clinical risks of patient deconditioning and infection. This remains a focus of the inpatient flow programme. 3. Mental health patient demands have also increased noticeably over previous years with patients requiring enhanced levels of support often at a significant cost premium to the trust. UHS continues to work with system providers on improvements for this patient group. Despite these pressures however the trust has continued to ensure value for money remains an organisational priority with £73m of savings achieved YTD particularly focused on transforming services under the three workstreams of theatre optimisation, outpatients and inpatient flow. The trust also continues to overperform on the elective recovery target which supports financial sustainability via increased tariff income and helps support waiting list reduction targets. Currently 126% of 2019/20 levels of elective, daycase and outpatient first attendances are being delivered compared to a target of 113%. YTD this has generated over £26m of additional income for the trust. Page 4 of 5 Further to this the trust remains on target to spend its full capital allocation for 2024/25 totalling over £95m including £20m on decarbonisation and improved energy infrastructure which is externally funded. This continued investment in capacity, digital and infrastructure helps support continued ongoing financial sustainability and efficiency improvements. Despite the scale of the financial challenge the trust continues to look forward with optimism that our investments in infrastructure and transformation provide the right “foundations for the future”, including sustainable finances, and supporting “world class people, delivering world class care” as outlined in our strategy. 6. Human Resources Indicator Staff recommend UHS as a place to work Staff survey engagement score (out of 10) Q3 24/25 68.3% 7.0 Q4 24/25 66.4% 6.8 Trust wide, we have maintained our above average position across all the People Promise domains in the annual staff survey (Q3), with results remaining broadly unchanged from 2023 across all questions, with minimal improvements or declines which would be considered statistically significant. Year-on-year results over a three-year period shows there to be continued improvements in relation to satisfaction with immediate managers, opportunities for flexible working, appraisals, and increased confidence in reporting of incidences of unsafe practice, violence, bullying and harassment. However, we continue to see downward trends associated with civility and respect, and team dynamics which align to the themes in recent patient safety events and F2SU themes. Additionally, our national ranking for recommendation as a place to work has improved four places from last year, we now rank 18th out of 122 trusts, compared to 22nd in 2023. Participation rate has continued to decline to 39% from 41% in 2023, a 15% drop since 2022. This represents a total participation of 5,410 people out of a total eligible of 13,795 including subsidiaries. When reviewing the quarterly survey results, such as Q4 above, it must be noted that these results are less representative of views across UHS as we hear from less people. We maintain around a 20% response rate with quarterly surveys, hearing from 2,878 staff in Q4 out of an eligible 14,636 (this number is higher as more staff are eligible to participate in the quarterly surveys. WPL do their own quarterly survey so are not included). Indicator Target January 2025 Staff Turnover (internal target; rolling 12 month) Sickness absence 12 month rolling (internal target) 75% of staff in each area has received training, including neonatal medical team. • Trolley dashes. • Train the trainer. Progress Metrics Audit of compliance: • Has it been undertaken for the appropriate babies? • Was the frequency of observation undertaken correctly? • Was the score accurately calculated? • Did escalation take place if required? • Was the response to escalation appropriate? Quality Improvement Priority Four: Implementation of the National Safety Standards for Invasive Procedures (NatSSIPs) 2 at UHS. Core Dimension Patient Safety Rationale for Selection The new National Safety Standards for Invasive Procedures (NatSSIPs 2) represent the progression of the original NatSSIPs. The key aim to standardise, harmonise and educate (SHE) across organisations and procedural teams remains central to the NatSSIPs purpose. Critical changes include bolstered organisational standards and proportionate checks that recognise different levels of risk during major and minor invasive procedures, and the adaptions to processes that may be necessary in life-threatening situations. This standardisation, harmonisation and education goals are set out in the table below. Investigations into the increase of never events in 2023 and 2024 has identified that the majority of these had contributing factors related to stop points for safety. The key learning identified: All these factors will be addressed through NatSSIPs2 implementation. Safer invasive procedures is to be included as a local quality indicator by the ICB within the 2025/26 national contract. Key Aims • Establish a NatSSIPs oversight committee. • Set up an invasive procedures committee. • Establish the following workstreams: o Audit of stops point for safety in theatres and for minor procedures in outpatient and ward areas o Multi-disciplinary safety walkabouts o VLE and induction workstream • Education: recruitment of medical education led to set up simulation-based MDT training. • Patient involvement • NatSSIPs 8 and communications. • Stop points for safety staff resources. Progress Metrics • Increase in the completion of VLE stop points training. • Develop and implement a programme to deliver non-technical skills to the MDT. • All areas with a never event in the last two years have an up-to-date audit and action plan for compliance with NatSSIPs2. Quality Improvement Priority Five: Fundamentals of Care Core Dimension Patient safety Rationale for selection The term Fundamentals of Care (FoC) describes the eight standards that staff across the Trust have committed to in collaboration with the patient, to support the physical and emotional needs of patients’, relatives, and carers. This is not a new concept, it underpins the core values of what it means to be a healthcare professional, to truly ‘care’ and will build upon our achievements in year one. Operational challenges have led the workforce to become more task-focused and less person-focused, taking away from that personalised care experience but we are committed to changing that culture, following our trust value, Patients First. The FoC exemplifies how the interdisciplinary team connects and builds relationships with our patients, getting to know them and what matters to them as a person, not just as a patient, supporting and encouraging independence and rehabilitation from the beginning of their hospital stay. These activities are the essentials of our daily living such as personal hygiene, skin care, oral hygiene, toileting, eating and drinking, and mobilising. Communication is also essential and includes both listening and hearing patients, understanding what is important to them using communication tools they need, coming to shared decisions with patients about their care and recognising the diversity of our population, embracing accessibility for those with people with learning disabilities, sight/hearing loss or other disabilities, or if English may not be their primary language. In addition, the FoC encourages us as healthcare professionals to consider the whole person, support cultural, spiritual, mental health, emotional wellbeing and dignity needs of people we care for and those that matter to them. We know here at UHS that not everyone experiences this level of care, but we acknowledge the need to change the rhetoric from ‘we are busy’ to ‘we are never too busy to care’ empowering and educating our staff at all levels to challenge the ‘we have not got time’ rhetoric and ensure fundamental care is at the heart of what we do at UHS. Thus improving, patient care and experience. Key Aims We will grow the multi-disciplinary engagement and involvement in workstreams that embrace the FoC and encourage person centred to care. We will continue to pursue the digitalisation of the Friends and Family Test (FFT), using this data and the national inpatient and urgent and emergency care survey as a baseline, while linking with involved patients where required with to encourage feedback on the FoC. We will listen to the voice of our patients, their relatives, and carers to make sure their stories and experiences are heard by our workforce to encourage the organisation wide change. We will ensure the FoC will has clear and measurable improvement metrics as part of a live clinical quality dashboard that will afford ward managers and senior leaders, the opportunity to monitor, review and report on to FoC in their areas. We will embed the FoC into the matron walkabout and CAS processes, supported by consistent evaluation metrics that ask the patients about their experiences and encourage clinical areas to continually assess and evaluate the FoC in their areas through a self-assessment tool. We will enhance the availability of existing resources on our virtual learning wnvironment (VLE) in collaboration with our patient partners for all staff groups and embed the FoC into training across the organisation, to improve the knowledge, skills and awareness ensuring the delivery of quality care. We will continue to test and evaluate the What Matters To Me project, growing our volunteer role to support staff in finding out what is important to the patient and using their personalised board to remind staff of the ‘person’ they are caring for. We will continue to establish project links in child health, maternity and outpatients to ensure a bespoke, but collaborative roll out of FoC, considering how these different care environments may impact care. Progress Metrics • Patient hygiene – We will see an improvement in the number of patients who report having their personal care needs met, particularly within their first 24 hours coming through emergency admission routes. • Skin integrity – We will support the reduction in incidences of avoidable pressure ulcers across the organisation. • Communication – We see an increase in the number of people accessing our interpreting services and a reduction in complaints related to interpretation. • Pain – We will see an improvement in patients reporting that their pain was well controlled when coming through the emergency department. • Mouthcare – We will see a positive uptake in the implementation of the new mouthcare assessment tool and an improvement in patients reporting that their oral hygiene needs have been met. • Nutrition and hydration – We will see an increase in patients reporting they are being offered adequate food and drink provisions throughout their hospital stay, including access to equipment for those with conditions or disabilities that impact their ability to do so independently. • Bowel and bladder care – We will see improved assessment of bowel and bladder habits through increased documentation using the Inpatient Noting system. • Enhancing safe movement – We will support a reduction in the incidence of high harm falls and high harm falls that have preventable causes. • Infection prevention – We will see a reduction in nosocomial infections through increased hand hygiene standards and more effective cleaning of equipment Quality Improvement Priority Six Develop the Trusts’ approach to reducing the impact of health inequalities (HIs) - year two. Core Dimension Clinical effectiveness Rationale for selection Tackling health inequalities is a key priority for the NHS. At UHS we have been working to have an impact on health inequalities for several years. In 2024/25 we formalised these efforts with a governing board, chaired by our chief medical officer and with a clear programme of improvement based on recognised priorities. This formed the basis of our quality priority in 2024/25. This year’s quality priority is a continuation of the work that started in 2024/25. We intend to continue to grow our understanding and actions as an organisation, improving the equity of access, outcomes and experience of our services across our community. Key Aims We are continuing our health inequalities board, with focus on five priorities: enabling our organisation, data and measurement, clinical service priorities, communication and engagement and strategy and approach. Each of these priorities have aligned directors to oversee improvement and a detailed delivery plan. Key priorities and expected outcomes from each of these are listed below: Enabling the organisation: • Developing supporting structures - set up governance so that teams who identify health inequality related issues know where they can go for help, so that we can understand frequently arising challenges and notice when a problem raised might be affecting other of the hospital too. This will aid improvement, learning from issues identified and escalation of issues that cannot be resolved locally • Capability building - develop training for our staff to understand health inequalities, identify them within services and access tools to make improvement. • Delivery of the health inequalities officer role - grow knowledge of the health inequalities officer role across the organisation and utilise this role to share knowledge, training and support improvements. Data and measurement • Continue to develop our understanding of inequalities in access across outpatients and diagnostics, inpatients, theatres and the emergency department. • Enable the measurement of improvement in areas recognised as clinical priorities. • Enable completion of national reporting. Clinical priorities • Improve services and support for patients and staff with obesity (children and adults). • Improve identification and control of hypertension. • Improve services and support for patients and staff who smoke. Communication and engagement • Adopt health inequalities into leadership and decision making. • Learning from our communities and our staff. • Communicating improvements internally and externally. • Staff support campaign. Strategy and approach • Overseeing and agreeing UHS approach and strategy for HIs. • Overseeing annual delivery against priorities. • Aligning programme resource. • Maintaining collaborative working with public health and Integrated Care Board teams and other local healthcare providers. • Keeping up to date with national recommendations and expectations, sharing this knowledge with our organisation. • Overseeing trustwide improvement and health inequalities maturity. Progress Metrics • Increasing numbers of staff trained. • Numbers of health inequalities issues reported (expected to increase through understanding before reducing due to improvement work). • Case studies shared of successful improvement projects. • Increased involvement and collaboration with patients and public on improvement. • Increased use of QEIA templates in decision making. • Demonstration of improved access to care for obesity, tobacco dependency and hypertension. 2.3 Statements of assurance from the Board This section includes mandatory statements about the quality of services that we provide relating to the financial year 2024/25. This information is common to all quality accounts and can be used to compare our performance with that of other organisations. The statements are designed to provide assurance that the board of directors has reviewed and engaged in cross-cutting initiatives which link strongly to quality improvement. 2.3.1 Review of services During 2024/25 UHS provided and/or sub-contracted 118 relevant health services (from total Trust activity by specialty cumulative 2024/25 contractual report). UHS has reviewed all the data available to them on the quality of care in all these relevant health services. The income generated by the relevant health services reviewed in 2024/25 represents 100% of the total income generated from the provision of relevant health services by UHS for 2024/25. 2.3.2 Participation in national clinical audits and confidential enquiries The UHS clinical audit programme was developed in support of the Trust’s vision by putting patients first, working together and always improving. This leads on to a specific strategy for clinical outcomes, to ensure robust and measurable processes are in place to plan locally and participate strategically. Healthcare Quality Improvement Partnership (HQIP) produces a National Clinical Audit & Enquiries Directory which identifies those national audits which are included in the NHS England Quality Account List 2024/25, those audits which are part of National Clinical Audit and Patient Outcomes Programme (NCAPOP). NCAPOP audits are commissioned and managed on behalf of NHS England by HQIP. These collect and analyse data supplied by local clinicians to provide a national picture of care standards for that specific condition. On a local level, NCAPOP audits provide local trusts with individual benchmarked reports on their compliance and performance, feeding back comparative findings to help participants identify necessary improvements for patients. The audits listed on the NCAPOP are ‘must-do’ national audits. The quality accounts national clinical audit list includes audits which we regard as ‘best practice’ to participate in (in addition to those from the NCAPOP) and for that reason we always include these in our corporate audit plans as a priority where they are relevant to our Trust. UHS has a strong history for completing clinical audits. The clinical effectiveness team has a robust approach to governing and supporting the completion. We’ve opened discussions with senior clinical leadership within Hampshire and Isle of Wight Integrated Care Board regarding the current challenges with contributing to and using the outputs of national audits. Benchmarked data resulting from national audits provides strong guidance on areas of excellence and improvement, however completion can be challenging in its complexity and resource intensiveness, and timeliness of outputs can reduce our ability to be responsive to indications. Real time data supports our clinical teams to be proactive in striving to meet our always improving objectives. During 2024/25 68 national clinical audits and four national confidential enquiries covered NHS services that UHS provides. During 2024/25 UHS participated in 97% of national clinical audits and 100% national confidential enquiries of which it was eligible to participate in. NCEPOD studies participated in during 2024/25 were: • Emergency (non-elective) surgery in children and young people. • Juvenile idiopathic arthritis. • Blood sodium (hyponatraemia). • Acute Limb Ischaemic. UHS fully supports the Maternal, Newborn and Infant Clinical Outcome Review Programme (MBRRACE-UK) and all the reviews that take place under this umbrella. The national clinical audits that UHS participated in, and for which data collection was complete during 2024/25, are listed below (Table A) alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry if known at time of writing this report. Eligible (68) Participated 66 = 97%) Table A. Total number of NCAs UHS were eligible to participate in (n=68) % Actual cases submitted / expected submissions 1. BAUS Penile Fracture Audit ✓ Not yet started 2. BAUS I-DUNC (impact of Diagnostic Ureteroscopy on Radical ✓X Nephroureterectomy and Compliance with Standard of care practices) 3. BAUS Environmental lessons learned and applied to the bladder cancer ✓ care pathway audit (ELLA) 4. Breast and Cosmetic Implant Registry ✓✓ 5. Case Mix Programme (CMP) (ICNARC) ✓✓ 1677 for 3 quarters 6. Emergency Medicine QIPs – Time critical medications ✓✓ 63 pts 7. Emergency Medicine QIPs – Care of older people ✓✓ 182 pts 8. Falls and Fragility Fractures Audit Programme (FFFAP) national hip ✓✓ 971 all pts fracture database 9. Falls and Fragility Fractures Audit Programme (FFFAP) fracture liaison ✓ ✓ 2910 all pts database 10. Falls and Fragility Fractures Audit Programme (FFFAP) National Audit of ✓ ✓ Inpatient Falls 11. Learning disability and autism programme - Learning from lives and ✓✓ 100% deaths of people with a learning disability and autistic people (LeDeR) 12. National Adult Diabetes Audit – National Diabetes Inpatient Safety ✓✓ audit 13. National Adult Diabetes Audit – National Pregnancy in Diabetes ✓✓ 100% 14. National Diabetes Audit - transition ✓ ✓ Collects data from database 15. National Diabetes audit – gestational diabetes ✓ ✓ Collects data from database 16. National respiratory Audit Programme (NRAP) - asthma in children ✓✓ 17. National respiratory Audit Programme (NRAP) - asthma in adults ✓✓ 18. National respiratory Audit Programme (NRAP) - COPD secondary care ✓ ✓ 19. National respiratory Audit Programme (NRAP) Pulmonary rehabilitation ✓ ✓ 20. National Audit of Care at the End of Life (NACEL) ✓✓ 250 pts 21. National Cancer Audit Collaborating Centre - National Audit of ✓ ✓ Data entry not Metastatic Breast Cancer required 22. National Cancer Audit Collaborating Centre - National Audit of Primary ✓ ✓ collected Breast Cancer nationally 23. National Cancer Audit Collaborating Centre – National Kidney Cancer ✓✓ Audit (NKCA) 24. National Cancer Audit Collaborating Centre – Non-Hodgkin Lymphoma ✓ ✓ Audit (NNHLA) 25. National Cancer Audit Collaborating Centre –National Pancreatic ✓✓ Cancer Audit 26. National Cancer Audit Collaborating Centre - National Bowel Cancer ✓✓ Audit (NBOCA) 27. National Cancer Audit Collaborating Centre - National Oesophago- ✓✓ gastric Cancer (NOGCA) 28. National Cancer Audit Collaborating Centre - National Lung Cancer ✓✓ Audit (NLCA) 29. National Cancer Audit Collaborating Centre - National Prostate Cancer ✓ ✓ Audit (NPCA) 30. National Cardiac Arrest Audit (NCAA) ✓✓ 150 Approx 31. National Cardiac Audit Programme (NCAP) - Adult cardiac surgery ✓✓ 32. National Cardiac Audit Programme (NCAP) - Cardiac Rhythm ✓✓ Management (CRM) 33. National Cardiac Audit Programme (NCAP) - congenital heart disease ✓✓ (CHD) paeds 34. National Cardiac Audit Programme (NCAP) - Heart Failure audit ✓✓ 35. National Cardiac Audit Programme (NCAP) - Acute Coronary Syndrome ✓ ✓ 100% or Acute Myocardial Infarction 36. National Cardiac Audit Programme (NCAP) - Percutaneous coronary ✓✓ 100% interventions (PCI) 37. National Cardiac Audit Programme (NCAP) - The UK Transcatheter ✓✓ Aortic Valve Implantation (TAVI) Registry 38. National Cardiac Audit Programme (NCAP) -Left Atrial Appendage ✓✓ Occlusion (LAAO) Registry 39. National Cardiac Audit Programme (NCAP) – Patent Foramen Ovale ✓✓ Closure (PFOC) Registry 40. National Cardiac Audit Programme (NCAP) – Transcatheter Mitral & ✓✓ Tricuspid Valve (TMTV) Registry 41. National Child Mortality Database (NCMD) ✓✓ 100% 42. National Clinical Audit of Seizures and Epilepsies for Children and ✓✓ *1 pt Young People (Epilepsy12) 43. National Comparative Audit of Blood Transfusion – Audit of NICE ✓✓ Quality Standard QS138 44. National Comparative Audit of Blood Transfusion – Bedside Transfusion ✓ ✓ Audit 45. National Early Inflammatory Arthritis Audit (NEIAA) ✓✓ 46. National Emergency Laparotomy Audit (NELA) - Laparotomy ✓✓ 47. National Emergency Laparotomy Audit (NELA) – No lap ✓✓ 48. National Joint Registry ✓ ✓ 834 (data run to 10/02/2025) 49. National Major Trauma Registry ✓ ✓ 600 for 3 quarters 50. National Maternity and Perinatal Audit (NMPA) ✓✓ 51. National Neonatal Audit Programme (NNAP) (Neonatal Intensive and ✓✓ 100% Special Care) 52. National Ophthalmology Audit Database ✓✓ 53. National Paediatric Diabetes Audit ✓✓ 54. National Vascular Registry (NVR) ✓✓ **100% 55. Paediatric Intensive Care Audit Network (PICANet) ✓✓ 100% 56. Perinatal Mortality Review Tool (PMRT) ✓✓ 100% 57. Perioperative quality improvement programme ✓✓ 12 pts 58. Quality & Outcomes in Oral & Maxillofacial Surgery (QOMS) – Oncology ✓ Data taken & reconstruction straight from 59. Quality & Outcomes in Oral & Maxillofacial Surgery (QOMS) – Trauma ✓ other 60. Quality & Outcomes in Oral & Maxillofacial Surgery (QOMS) – ✓ databases Orthognathic surgery 61. Quality & Outcomes in Oral & Maxillofacial Surgery (QOMS) – Non- ✓ melanoma skin cancers 62. Quality & Outcomes in Oral & Maxillofacial Surgery (QOMS) – Oral & ✓ Dentoalveolar Surgery 63. Sentinel Stroke National Audit Programme (SSNAP) continuous SSNAP ✓ ✓ Clinical patient Audit, organisational audit 64. Serious Hazards of Transfusion (SHOT) UK National haemovigilance ✓✓ scheme 65. Society for Acute Medicine's
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Annual-report-24-25-final

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2024/25 Incorporating the quality account University Hospital Southampton NHS Foundation Trust Annual Report and Accounts 2024/25 Presented to Parliament
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Quality account 24-25 final

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QUALITY ACCOUNT 2024/25 QUALITY ACCOUNT Contents Part 1: Statement on quality from the chief executive 1.1 Chief executive’s
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